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Re: Depo provera and lactation -- REPLYFrom: Dean Huffman (jth@springnet1.com)Thu Mar 29 19:39:50 2001
.. Actually, the URL is not of all that much significance. If one has access to the ACOG web site, then just log on, go to the area were documents can be downloaded, check Technical Bulletins only, then search on 258. If one does not have access to all of the ACOG site, then the URL is worthless anyway since access will be denied. The relavent part of the document states: Progestin-Only Contraceptives Progestin-only contraceptives, including progestin-only tablets (minipills), depot medroxyprogesterone acetate (DMPA), and levonorgestrel implants, do not affect the quality of breast milk and may slightly increase the volume of milk and duration of breastfeeding compared with nonhormonal methods (28-32). Accordingly, progestin-only methods are the hormonal contraceptives of choice for breastfeeding women. Nonetheless, some authorities have recommended delays of various lengths before introduction of progestin-only contraceptives on the basis of two sets of theoretical concerns: - The normal 2-3-day postdelivery decrease of progesterone is part of the process that initiates lactation. There is theoretical concern that giving progestins in the first few days before lactation is established could interfere with optimal lactation. Note that DMPA enters the milk at approximately the same level found in the woman's blood; by contrast norgestrel and norethindrone enter the milk at only one tenth the level in the woman's blood. The injectable route of administration also may result in a comparatively high initial dose (27). - Progestin methods carry a theoretical risk to the newborn because of exposure to exogenous steroids at a time when the newborn's system is very immature in its ability to metabolize drugs. Because of this concern, research studies presented to the FDA for drug approval investigated only the effects of these methods administered several weeks after birth. Because documentation of experience with earlier initiation was not presented to the FDA, package inserts recommend initiation of progestin-only oral contraceptives at 6 weeks for women who are exclusively breastfeeding and at 3 weeks for those who are breastfeeding with supplementation. Most authorities recommend introduction of long-acting progestin-only injectables or implants 6 weeks after delivery for breastfeeding women (27, 33, 34). To balance these conservative recommendations, it is important to understand that the few studies that included early administration of progestin-only methods-oral contraceptives at 1 week postpartum (35, 36) and injectable medroxyprogesterone acetate at 2 days (37) and 7 days (38)-found no adverse effects on the newborn or on breastfeeding. In the absence of evidence that earlier introduction of progestin-only contraceptives has adverse effects on the newborn and on breastfeeding, the labeling for progestin-only oral contraceptives focuses instead on what is known about fertility after childbirth. Taking only biologic factors into account, contraception is not needed in the first 3 weeks postpartum because of a delay in return of ovulation in all women. And this delay is extended for women who breastfeed exclusively. An implied prohibition on earlier administration is more in the nature of a pragmatic rather than a scientific resolution of the question. From the perspective of routine clinical practice, it would appear reasonable to apply the same rationale, even though conservative, to the initiation of DMPA and implants in postpartum breastfeeding women. However, the package labeling for these methods has the effect of being even more conservative as noted, outlining a 6-week start for all breastfeeding women, with no flexibility. Sometimes, however, there are practical reasons a breastfeeding woman may consider initiating hormonal contraception while in the hospital or shortly after. For example, there may be uncertainty about opportunities for follow-up visits. The breastfeeding woman and her physician can then weigh the reasons for early use of these contraceptives against potential disadvantages, make an appropriate decision, and continue to evaluate the woman's individual breastfeeding experience if hormonal contraceptives are chosen.
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